“What’s the ending mean22?” he asked.
“That you have your choice between ignorance and survival or knowledge and death.”
“And?”
“And what?”
He told me that Miller had been a tail gunner in World War II who had participated in the destruction of Montecassino, a Benedictine abbey in Italy. “He wrote the book as an expiation. He’s writing about wise guys like you and me throwing hand grenades at traditions that we think are stupid. But those traditions have a value we might miss,” he said. “It’s the intellectuals who create the nuclear weapons. The dumb traditionalists turn out to have it right. A lot of false beliefs help people cope with life.”
Frances’s thin voice descended nearly into a growl. “So don’t throw grenades unless you know what you are doing, Gary. Don’t throw grenades. There are some traditions if you fuck with . . .” He trailed off. “You wouldn’t want to tell a placebo responder he’s on placebo.”
• • •
The APA wasn’t so happy with me, either.
Early in November, just about when Frances was admonishing me, I contacted its press office to clarify a point from my interview with Regier and to nail down the exact order of events that resulted in banishing the drug companies from its educational programs and from the stock portfolios of DSM contributors. I also asked if an APA official would comment on the psychologists’ petition, now that it had amassed so many signatures. So far the press office had stayed silent, except to note that the petition was just one of the “thousands of comments” that had been heaved over its transom—all of which were “being reviewed by task force and work group members.”
After a few days, I received this message23 from the APA’s director of communications, Eve Herold.
Dear Gary,
We have received several requests from you for access to APA experts and positions on issues related to the DSM for the book you’re writing. I wanted you to know that we will not be working with you on this project. Last year we gave you free access to several of our officers and DSM experts for the article you wrote for Wired. In spite of the fact that we went to considerable lengths to work with you, the article you produced was deeply negative and biased toward the APA. Because of this track record, we are not interested in working with you further as we have no reason to expect that we would be treated any more fairly in your book than we were in the Wired article.
I think she meant “biased against.”
Glad as I was to be spared the APA’s talking points, I didn’t understand why it would preemptively surrender its opportunity to correct my errors or respond to its critics, who they had to know were talking to me. I also wondered how Herold was going to stop her “experts”—at least the ones who didn’t work directly for her organization—from being in contact with me, which many of them had been doing all along, gladly and forthrightly. The confidentiality agreement hadn’t stopped them. Would a communiqué from headquarters?
But mostly I was wondering if I would lose my job as a Collaborating Investigator in the field trials. I’d already put in eight hours or so, completing the Field Trials Human Subjects Protection Basic Training and mastering the Informed Consent Process, learning how to fill out the Patient Log, how to Register the Patient, how to log onto the Portal, how to Push the Data to the Clinician Database, looking over the REDCap Flowchart and Disorder Quick Reference Troubleshooting Guide, reading the sixty-page System Manual, and sitting through the ninety-minute Webinar. I’d taken the quizzes and practiced on the case vignettes, and finally, just a week before Herold’s blow-off, I’d received an e-mail from the field trials team, informing me that I had completed the training and would soon be given access to the “LIVE database.” Had I worked so hard and come so far, only to be cut from the team just as I was about to take the field?
I had my answer the next day in an e-mail from the field trials’ operations manager. It wasn’t a pink slip at all, but rather a congratulations on my having successfully completed the DSM-5 field trials training, and a new login and password for the field trials site.
It was astounding that the APA would forgo the opportunity to spin its story to me—not to mention so baldly display its Kremlin tactics, and in writing no less—and yet let me in for an unfiltered look at their prized field trials. Most likely, no one had figured out that the biased writer and the Collaborating Investigator were the same person (although I made no effort to conceal this fact, using the same contact information in both capacities). But another e-mail from the operations manager—a note that had come just a few hours after Herold’s—suggested a different explanation. That message told me to disregard any e-mail I might have just gotten from her. As it happened, I hadn’t received anything. But just in case I wanted an opportunity to disregard it, she attached the errant e-mail. It was a note from Kupfer and Regier, thanking me (for the third time) for participating in the field trials, but also urging me to complete the training, and letting me know that the task force had extended the deadline to do so. “We realize how challenging it is24 for practicing clinicians to find time to participate in research,” they wrote, before reminding us about the CME credits and the free copy of the DSM-5, complete with our names listed in the back, that awaited us in May 2013.
It sounded as if they were having trouble getting those five thousand clinicians on board. Perhaps, like Michael First, who told me it was “hard to find a spare six hours to do it,” they were just too busy, or maybe they thought a free book and their name in agate type were insufficient compensation for the task. Whatever the explanation, it appeared that I was among the very few. I may have been persona non grata in the communications department, but over at the research department, people like me were much in demand. Plague rat or not, they couldn’t afford to toss me overboard.
Recruiting my first trial patient was easy enough. Lee and I were still in that phase of therapy in which we really liked each other—positive transference/countertransference, the Freudians would call it. She would not want to displease me—a good thing, as it turned out, when the test proved to take an hour and forty-five minutes to complete.
Not that Lee got nothing out of the deal. She did seem pretty thrilled to sit at my desk and use my computer. Back in the psychoanalytic days, surrendering my chair and my equipment would have been a meaning-rich event. What was it like for her to sit in my chair and use my computer? How did it feel to be asked for a favor by her therapist? That conversation is either silly or significant, depending on whether or not you believe that the secrets of who we are come into view most clearly in dreams and slips of the tongue and reactions to the unexpected, and deserve to be illuminated.
Lee and I did eventually talk about some of that. But those subjects hadn’t been covered in my training as a Collaborating Investigator. Instead, I’d been drilled on the necessity of obtaining explicit informed consent, which meant acknowledging that “there may be no benefit for the patient from participating,” and some risk—“that the patient may feel uncomfortable answering personal questions about thoughts and feelings.” But, I was to assure the subject, those risks were minimal, and the patient could always “talk to the clinician about any concerns or upsetting feelings,” and could bail at any time. I’d been warned to make sure she could not, while using my computer, gain access to confidential information. And, in the Webinar and the online training and the manual, I’d been given all the fine points of the software, how to save and retrieve and submit. Technical and legal considerations had replaced those hoary concerns about the actual meaning of the experience.
It’s hard to imagine Lee was finding much meaning as she clicked on the Level 1 cross-cutting measures and the Level 2 measures for the Level 1 domains—mood, anxiety, sleep, and substance use—she’d flagged as troublesome, and answered the WHO Disability Assessment Schedule questions about “getting along with people” and “participation in society.” N
either were we talking about what it meant for her to give me my chair and computer back, or watch me fumble through the next hour or so, opening the modules and going down the checklists and reading boldfaced alerts like this one:
To make the diagnosis of Major Depressive Disorder, one has to rule out whether the major depressive episode is better accounted for by Schizoaffective Disorder and is superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. To do so you SHOULD inquire about history of schizoaffective disorder, schizophrenia, and/or any psychotic symptoms!!
I navigated the menus and proceeded through the forty-nine pages of mood disorders and the thirty-one pages of anxiety disorders, the eighteen pages of sleep-wake disorders, the sixty-three pages of substance use disorders (many pages of which could be skipped simply by deciding that I did not want to explore the possibility that Lee suffered from cannabis use disorder or circadian rhythm sleep disorder, but it wasn’t entirely clear how I was supposed to know exactly which ones to skip; in all that training, I’d been left to my own devices to study up on the diagnoses themselves), and I concluded that she suffered from Major Depressive Disorder—Severe and Insomnia Disorder and Alcohol Use Disorder—in Full Remission, all the while feeling retroactive sympathy for Bill Narrow, who knew long before he put hand to mouse that Virginia Hamm was a hoarder just as much as I knew that Lee was a depressed insomniac with a drinking problem, but had to go through with the exercise anyway.
On the other hand, Narrow had a part in designing this 501-page monster and I didn’t.
But what about when the fix wasn’t in? What about someone I didn’t really know? The second interview I was supposed to conduct was with a new patient, and Claudia fit the bill. She had shown up on a rainy night twenty minutes late for her first visit after three increasingly frenzied phone calls in which I assured her that her GPS was correct about how to get from where she was to my building and one more as she wandered the hallways looking for my office, which she did not find until, after another phone call, I went out to meet her. She was easy enough to spot, a tiny woman with a pixie haircut, frantically flitting from doorway to doorway like a lost Tinker Bell. When I found her, she pressed her hands together under her chin Namaste-style and bowed slightly, my credibility as guru evidently established simply by my knowing my way around my building. It was a gesture she repeated three or four times in the course of our visit, just after I’d made a comment. After she left, I tried but could not for the life of me recall what those comments might have been. It’s possible my memory got lost in the jumble of details that poured out of her mouth at top speed (she suffered from what we therapists call logorrhea), but more likely, I hadn’t said anything particularly insightful, being too busy absorbing her distress and confusion, her depression and anxiety and paranoia, her fragmented stories of her fraught love affairs with men and women, the way she flew from bed to bed like a hummingbird, alighting just long enough to sip some nectar, searching for the next flower before she was even finished with the last—the most recent being a man whom she had, after a flurry of texts and e-mails and aborted trysts, accompanied to a hotel room, only to find his girlfriend already installed, and she, for reasons she couldn’t quite explain, but maybe it was the three martinis they drank, went ahead with his suggested sexual encounter with the girlfriend—and her troubles at her graphic design job, which she was afraid she was about to lose, or maybe she had lost already, she wasn’t sure, but she was too afraid to ask her boss, with whom she had been having sex, but who was leaving the company and his replacement was gay, so he probably wasn’t going to exchange job security for sex (not, she assured me, that this was what she’d been doing with the boss). Plus which she somehow had ended up with the boss’s pet birds, three squawking cages full, who needed care and feeding beyond what she could give any longer, and what she really wanted to know from me was what to do about the birds.
Being with Claudia was like riding a raft through white water. I might be skeptical of the value of the DSM, but I was ready to try anything to channel these rapids into an orderly stream of information, a diagnosis that would grant me the ability to communicate efficiently about Claudia to at least one clinician—me. So I was glad to offer her the opportunity to participate in the study (and the free visit in return), and she, for reasons she never stated, but most likely at least in part because she didn’t exactly know how to say no to men, was glad to consent.
The very next week, after one more visit, one more fruitless attempt to piece together some coherent story out of the fragments of her life, I surrendered my desk and computer to Claudia. Her finger hovered above the mouse frequently as she read over the items, sometimes out loud. She sighed and laughed and, a couple of times, had an extended conversation with the computer (only one side of which I could hear). Twice she came to a complete stop, staring at the screen for a minute or so without scrolling or clicking or reading, transfixed, I thought, by something else entirely. After forty-five minutes, she stood up, made her little bow, and returned to her chair.
I pushed the data. We had our work cut out for us. She’d scored high in all the cross-cutting domains except substance use, where she had a zero—a strange result, I thought, since so many of the escapades she had described in our first session were fueled by alcohol. I fumbled through the diagnostic interview a little less with her than I had with Lee. But then again, I had more time to plot my course through the criteria while Claudia pondered every question closely. She wasn’t sure if she had “feelings of worthlessness or excessive and inappropriate guilt” or “excessive anxiety” or a “distinct period of abnormally and persistently elevated, expansive or irritable mood that lasted 4 consecutive days and was present most of the day nearly every day.” She would give an answer and take it back and venture another, hovering over her response like a checkers player who never lifts his fingers from his piece, until I finally had to say, “Let’s go on,” and she let the last move stand.
Claudia was certain about some criteria. She did not drink too much. She was not confused about sex. And she did not have a “diminished ability to think or concentrate, or indecisiveness.”
I don’t think she was lying. I think she was, as we therapists say, in denial. And who could blame her? She was too mercurial for introspection, and even if she hadn’t been, these weren’t exactly the best conditions under which to reveal her frailties and flaws. I was, after all, still more or less unknown to her, our lack of intimacy at wild odds with my probing, no less so than it is in the gynecologist’s office, only here there was no sheet to cover her, no nurse to hold her hand or distract her, and I was not crouched where she couldn’t see me, but looking right in her eyes as I asked questions made indecent by their detachment from anything real or live between us. Efflorescent inner life rendered as symptom by a stranger wielding the DSM’s computerized language as if it were a speculum: who would not resist?
It had been a little more than an hour since Claudia had relinquished the computer, nearly two hours since we had started this dispiriting adventure. I decided to skip the substance use disorders despite my doubts about her answers and click right to the part I had originally thought might yield something useful, a way to organize my own thoughts in the face of her chaos: the personality disorders section.
At first, it looked straightforward enough. There was ample “evidence of impairments” in her “experience of self as unique with clear boundaries between self and others,” in the stability of her self-image and her “ability to regulate [her] emotional experience.” Yes, she had some problems with intimacy. But how much impairment? REDCap wanted to know. On a scale of zero to four, just how fucked up was Claudia?
Here I was given a choice. I could “proceed directly to rating” and pull a number out of the air, or I could get a “detailed description of levels.” I went for the details, which turned out to be extensive, three pages of description
about “identity” and “self-direction” and “empathy” and “intimacy.” Was she a Level 2—“Excessive dependence on others for identity definition, with compromised boundary delineation”? Or did she have the “weak sense of autonomy/agency” and “poor or rigid boundary definition” of a Level 3? Or was her experience of autonomy/agency “virtually absent,” and her boundaries “confused or lacking,” which earned her a Level 4? Was her self-esteem “fragile” (Level 3) or merely “vulnerable” (2), or perhaps riddled with “significant distortions” and “confusions” (4)? Was her capacity for empathy “significantly compromised,” “significantly limited,” or “virtually absent”? Was her desire for connection with others “desperate,” “limited,” or “largely based on meeting self-regulatory needs?”
I had no idea. And even if I had, or if I knew how to get this confused and confusing woman to parse it for me, there still loomed thirty pages or so to get through, box after box to check about her self and interpersonal functioning, her separation insecurity and depressivity, her negative affectivity and disinhibition, the types and facets and domains of her traits, hundreds of boxes, or so it seemed, before I could make my final diagnosis, and, with the authority vested in me as a Collaborating Investigator of the American Psychiatric Association, determine which of the constructs that deserve neither denigration nor worship, that aren’t real but still can be measured from zero to four, that need to be taken seriously enough to warrant payment and maybe a round of medication but not so seriously that anyone would accuse them of existing, which fictive placeholder would join her height and blood pressure and her childhood illnesses and surgeries and all the other facts of her medical life. At which point I realized that no matter what diagnosis I settled on, I wouldn’t so much have tamed her rapids as funneled them into the diagnostic turbines, raw material for the APA’s profitable mills.
The Book of Woe: The DSM and the Unmaking of Psychiatry Page 31
